Academic burnout syndrome associated with anxiety, stress, depression, and quality of life in Peruvian dentistry students: an analysis using a multivariable regression model

Burnout syndrome is characterized by emotional exhaustion, depersonalization, and diminished personal accomplishment, and in academic contexts manifests as emotional exhaustion, academic inefficacy, and cynicism. Dental students face unique demands including rigorous coursework, early clinical responsibilities, and performance pressure, which, per the Job Demands–Resources model, can lead to burnout when demands exceed available supports. Globally, high burnout prevalence is reported among healthcare trainees, and prior studies have linked heavy academic workload to burnout and depression among dental students. Reliable tools such as DASS-21 and EQ-5D are widely used to assess psychological distress and quality of life. In Peru, gaps remain regarding how year of study and sociodemographic factors moderate the associations between academic burnout and anxiety, stress, depression, and quality of life. This study aimed to establish the association between academic burnout syndrome and anxiety, stress, depression, and quality of life among Peruvian dentistry students, testing the null hypothesis that no such association exists.

The background synthesizes evidence that burnout affects 25–75% of healthcare professionals and often originates during training. Studies from South Korea reported links between heavy academic workload, increased burnout, and depressive symptoms among dental students, while an Iranian study found early warning indicators of distress (overload, underdevelopment). The Job Demands–Resources model frames how excessive academic demands relative to resources precipitate exhaustion and disengagement. Screening measures like DASS-21 (for anxiety, stress, depression) and EQ-5D (for quality of life) are validated across cultures and widely used in academic research. Prior work suggests variability in mental health prevalence among students depending on context, tools, and cut-offs, complicating cross-study comparisons. Notably, Peruvian dental education lacks studies on year-of-study effects and sociodemographic moderators in burnout-mental health relationships, and the relationship between quality of life and academic burnout has not been explored locally.

Design: Analytical cross-sectional study following STROBE guidelines. Setting and period: Conducted November–December 2023 at Universidad Privada San Juan Bautista (main campus in Lima and branch in Ica, Peru). Population and sample: The source population comprised 693 dentistry students (374 Lima; 315 Ica) across 1st–5th year. A finite population sample size estimation (95% confidence, 50% expected proportion, 5% margin of error) yielded n=248, but the study included all eligible students; final target population N=566 (110 first-year, 101 second-year, 165 third-year, 117 fourth-year, 73 fifth-year). Inclusion: enrolled in 2023-2 semester, ≥18 years, provided written informed consent. Exclusion: non-completion of questionnaire. Variables: Dependent variable—academic burnout syndrome (dimensions: emotional exhaustion, academic inefficacy, cynicism). Independent variables—depression, anxiety, stress, quality of life. Potential confounders—age group (≤21 vs >21 years), sex, year of study, marital status (single vs married/cohabiting), place of origin (capital vs province). Instruments: - Maslach Burnout Inventory—Student Survey (MBI-SS), validated for Peruvian university students: 5 items emotional exhaustion, 6 academic inefficacy, 4 cynicism; Likert 1–7 (Never to Always). Internal consistency: emotional exhaustion α=0.883 (95% CI: 0.867–0.897), academic inefficacy α=0.889 (0.874–0.902), cynicism α=0.800 (0.772–0.825). Cut-offs: emotional exhaustion ≥32 (positive), academic inefficacy ≤17 (positive inefficacy), cynicism ≥15 (positive). Livingston’s K²: 0.886, 0.890, 0.908. - DASS-21: 7 items each for depression, anxiety, stress; Likert 0–3. Internal consistency: depression α=0.880 (0.864–0.895), anxiety α=0.861 (0.843–0.878), stress α=0.864 (0.846–0.881). Cut-offs: depression ≥5, anxiety ≥4, stress ≥8. Livingston’s K²: 0.884, 0.886, 0.864. - EQ-5D: domains mobility, self-care, daily activities, pain/discomfort, anxiety/depression. Good quality of life classified if all items scored 1; any deviation classified as diminished quality of life. Procedure: Paper-based, in-person administration by the principal investigator (JMR) with study explanation. Consent obtained on first page; instructions followed. Participants could decline or omit responses; one participation per student. Identifiers (initials+age, e.g., JMR22) used to detect duplicates. Data stored securely by the principal investigator; no incentives; individual results emailed upon request. Data analysis: SPSS v28 used. Descriptive statistics: frequencies and percentages for qualitative variables; mean, median, SD for age. Poisson multiple regression with robust variance estimated adjusted prevalence ratios (APR) for associations of depression, anxiety, stress, and quality of life with burnout dimensions, controlling for confounders. Significance p<0.05. Ethics: Approved by the Institutional Research Ethics Committee of Universidad Privada San Juan Bautista (Letter No. 1434-2023-CIEI-UPSJB, dated 23 Oct 2023). Conducted per Declaration of Helsinki principles; voluntary written informed consent obtained.

Participant characteristics: Mean age 22.3±4.7 years; 52.7% ≤21 years; 63.3% female; most in 3rd year (29.2%); 87.1% single; 49.6% from capital and 50.4% from provinces. Prevalence: Academic inefficacy 58.1% (95% CI: 54.1–62.2%), emotional exhaustion 49.8% (45.7–53.9%), cynicism 15.2% (12.2–18.2%). Depression 57.2% (53.2–61.3%), anxiety 68.4% (64.5–72.2%), stress 48.1% (43.9–52.2%). Good quality of life 41.5% (37.5–45.6%). Multivariable Poisson regression (APR, robust variance): - Academic inefficacy: Depression APR=0.65 (95% CI: 0.54–0.78); Stress APR=0.77 (0.63–0.94); First-year vs fifth-year APR=1.54 (1.23–1.92). Anxiety and quality of life not significant after adjustment. - Emotional exhaustion: Anxiety APR=0.77 (95% CI: 0.63–0.95). Depression, stress, quality of life, and sociodemographics not significant after adjustment. - Cynicism: Depression APR=3.72 (95% CI: 2.12–6.53); Stress APR=1.59 (1.06–2.40). Female sex APR=0.62 (0.43–0.89) vs male. Year of study vs fifth-year: 1st-year APR=0.20 (0.09–0.47), 3rd-year APR=0.44 (0.26–0.75), 4th-year APR=0.37 (0.20–0.69) indicating lower cynicism. Quality of life not significant. Quality of life: No significant association with emotional exhaustion, academic inefficacy, or cynicism.

Anxiety was the most prevalent psychological condition, followed by depression and stress, aligning with some international findings though differing where stress predominates, likely due to contextual and measurement differences. Academic inefficacy was the most common burnout dimension, then emotional exhaustion and cynicism. Unexpected inverse associations were observed: depression and stress associated with lower academic inefficacy, and anxiety with lower emotional exhaustion. These may reflect adaptive coping, resilience, or reverse causality inherent to cross-sectional designs; thus, caution is warranted in interpreting them as protective. First-year students were more likely to report academic inefficacy than fifth-year students, consistent with developmental gains in metacognition, self-regulation, and resilience across training. Cynicism was positively associated with depression and stress, consistent with literature linking cynical hostility to stress and adverse mood. Female students had lower cynicism, potentially reflecting gendered coping patterns. Lower cynicism among earlier years compared to fifth-year suggests cynicism may emerge as a response to escalating clinical responsibilities and fatigue near program completion. Quality of life (EQ-5D) showed no significant associations with burnout dimensions, possibly due to the instrument’s limited sensitivity to academic-specific psychological stressors; students may maintain acceptable overall HRQoL despite high academic strain. The study leveraged validated instruments (MBI-SS, DASS-21, EQ-5D) and multivariable modeling to account for confounders, but cross-sectional design, potential social desirability bias from in-person administration, and measurement limits may have influenced results. Findings support early, tailored interventions, resilience-building curricula, and targeted support for high-risk groups (e.g., first-year and male students).

Academic burnout among dental students is multifaceted. Depression and stress were associated with reduced academic inefficacy and cynicism, while anxiety was inversely associated with emotional exhaustion; quality of life showed no significant protective role. Interventions should be multidimensional and tailored to academic stage—particularly focusing on first-year students—and consider sex-specific strategies to mitigate risk in vulnerable subgroups.

- The sample was from a single university and is not representative of all Peruvian dental students. - Cross-sectional design precludes causal inference and assessment of longitudinal effects. - In-person administration by the principal investigator may have introduced social desirability bias and reduced perceived anonymity. - Measurement bias may have contributed to unexpected inverse associations; instruments may not fully capture psychological symptoms or academic distress. - Potential residual confounding from unmeasured or insufficiently controlled variables. - EQ-5D may lack sensitivity to academic stressors, limiting detection of associations with burnout dimensions.